Sleep Phase Disorder
In The News.....
-St. John's Wort


Sleep Phase Disorder
or "he/she stays up so late and then sleeps the day away!"

Preschool age children typically need 10-12 hours of sleep, elementary school age children need 8-10 hours, while teens and adults need about 8 hours. Right?... Well, not quite. The need for sleep varies quite a bit from person to person but generally does follow the age pattern above except for teenagers.

Sleep studies show that adolescents need as much sleep as younger children, 8-10 hours for most. Our society operates under the theory that teens actually need less sleep and even incudes a later bedtime as a sign of developing maturity. The result is that many teens (and young adults) try to get by on 6-8 hours which leaves a sleep debt building up night after night. The bad news is that the sleep debt must be paid in full, and soon, or suffer the consequences.

So, the sleep deprived teenager either goes to bed early or sleeps in, usually on the weekend. After getting up around noon on Saturday the debt is pretty well paid...that is until the teen stays up Saturday night and then sleeps in on Sunday AM (or takes a nap.) Now, he or she isn't tired at a reasonable bedtime on Sunday night because of sleeping in or taking a nap.

Then s/he has to get up early for school Monday morning ... bang!. back into sleep debt!

So, how do you recognize chronic sleep debt? The #1 sign is difficulty getting up and out of bed on one's own in the morning. Other signs include chronic fatigue, increased grouchy or irritable behavior, less sharp thinking, and moodiness; all this improves with a good night's sleep.

This pattern gets amplified with long school breaks such as 3 day weekends, Thanksgiving break, Christmas break, spring break, and the worst of all...summer. Frequently the youth is allowed or demands to sleep in "because it's vacation." When the sleep debt gets chronic, a pattern of staying up late (midnight, 2 AM or even later) and sleeping late (11 AM, noon, or even later) takes hold and for many becomes virtually unchangeable, "I can't go to sleep even if I do go to bed earlier!", "I can't get up earlier even if I want to!". This is now called Sleep Phase Disorder and is a diagnosable disorder of sleep. This is very similar to what shift workers experience and is like the severe jet lag of flying to Europe or Asia and back. Some people are little affected by such sleep cycle shifts, some become stuck in this new pattern for decades (eg., college students sleeping through afternoon classes), some are just called "night owls" who choose to work evening or night shift, and most struggle greatly (or should I say their parents struggle greatly) trying to reset their clocks; not really understanding what they have done to themselves. I see this often, especially after the long Christmas break and as summer ends and school begins each year.

What is the treatment? The best answer is easy to say but hard to do. The teen "simply" has to get up early every day for a week to reset their body clock which will then allow him or her to fall asleep normally at a reasonable hour. To prevent relapse he or she must then maintain that schedule, sleeping in only on rare occasions. Going to bed earlier won't help, and won't be successful as long as getting up late and/or taking naps is continued. Medications will not do it alone and are best avoided if possible. This process will be very difficult the first few days as s/he will have to drag him/herself out of bed and go on for several days feeling miserable until the sleep cycle switches back to normal. Then s/he can get to sleep at 9,10, or 11 PM and awaken early (6 to 9 AM), feeling refreshed after 8-10 hours of sleep. This will take 3 to 7 days.

Other "sleep hygiene" steps that may ease the path include avoiding caffeine, nicotine or other stimulants close to bedtime, exercising (but not just before bed), and allowing some wind down time before going to bed, such as relaxation tapes, reading, meditation, prayer or restful music.

As mentioned earlier, some people can make this adjustment easier than others. I have seen teens and young adults who sleep through multiple alarms, door pounding, yelling, water dumpings and being dragged out of bed. As mentioned above, some choose to lead an "evening shift" lifestyle which unfortunately doesn't fit well with the primary job of children and teens...school. Two of the other most powerful motivators to get up early regularly for older teens and young adults are a paying job and/or a baby (not yet please!). Once sleep phase disorder is identified, the treatment is straightforward.

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In The News.....

St. John's Wort (Also Known As Hypericum)

St John's Wort is the common name for the flowering plant officially known as Hypericum perforatum. This herb has recently been touted in the media as a possible treatment for mild to moderate depression. Generally, the claims are that St. John's Wort is more effective than a placebo, is roughly equal to standard antidepressants, and has a very low rate of side effects when used to treat mild to moderate depression.

There have been no studies on St. John's Wort published in the United States medical literature. Thus, the accepted scholarly journals, newsletters, and texts either do not address this herb or report its having no proven usefulness. In 1996 a British journal reviewed findings of several studies done in Europe concluding it is worthy of additional study.

Concerns about the quality of the studies done in Europe come from several directions. The most obvious is that the antidepressants compared to St. John's Wort were all old ones (Imipramine, Desipramine, Amitriptyline, Valium and Maprotiline) and are given at doses too low to be helpful but high enough to cause side effects (25 to 75 mg). In fact, Maprotiline is rarely used any more in the US and Valium is not even an antidepressant. The other three are tricyclic anti-depressants that are very effective but have dropped to 2nd or 3rd or lower choices simply because of having higher side effect rates than the newer antidepressants.

The antidepressants we use first now are usually the SRI group (Prozac, Zoloft, Paxil, Luvox), or Wellbutrin, Serzone or Effexor).

The studies do indicate a side effect rate up to about 25% with St. John's Wort usually consisting of gastrointestinal complaints, sedation, or nervousness. These appear to be typically mild to at most moderate.

There is the potential of serious skin sensitivity with sun exposure (photo toxicity) which has killed sheep grazing the plant but apparently has not harmed any humans. The studies also indicate that St. John's Wort is slower to work than typical antidepressants often taking up to 2 or 3 months to fully kick in.

The way St. John's Wort may work is only conjecture at this point. The current theories include partial serotonin, norepinephrine, and/or cortisol action. Since we do not know how it works we cannot know well its possible interactions. There are no studies addressing its use in combination with antidepressants or about how to switch from one to the other.

The cost of St. John's Wort depends on the dose taken, the preparation purchased, and the company or store where it is purchased. A reasonable estimate is $15 to $40 a month and is not covered by insurance due to being considered experimental. It is also usually taken three times a day, which can be a convenience problem.

In summary: Despite the serious weaknesses of and the lack of quality studies on using St. John's Wort (Hypericum) for the treatment of depression there seem to be enough promising signs to justify further research. A site on the Internet says that US researchers from the National Institutes of Health's Office of Alternative Medicine are planning a large multi-center trial of the herb. Even those encouraging its use say it is slow, is not to be used for more serious depressions or manic-depression (Bipolar Disorder), and make no claim for its helping anxiety disorders or other conditions beyond mild to (maybe) moderate depression. They advise against switching to St. John's Wort from a medicine that is working, and clearly advise persons taking it to be followed by a physician. Psychotherapy and/or well studied medications show success rates in the 70 to 80% range ---better than treatments in most other areas of medicine. St. John's Wort is not ready for prime time as an antidepressant.

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